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    Fap5 lecture ch03 Fap5 lecture ch03 Presentation Transcript

    • Chapter 3 Clinical Assessment, Diagnosis, and Treatment
    • Clinical Assessment: How and Why Does the Client Behave Abnormally?
      • What is assessment?
        • The collecting of relevant information in an effort to reach a conclusion
        • Clinical assessment is used to determine how and why a person is behaving abnormally and how that person may be helped
          • Focus is idiographic – on an individual person
          • Also may be used to evaluate treatment progress
    • Clinical Assessment: How and Why Does the Client Behave Abnormally?
      • The specific tools used in an assessment depend on the clinician’s theoretical orientation
      • Hundreds of clinical assessment tools have been developed and fall into three categories:
        • Clinical interviews
        • Tests
        • Observations
    • Characteristics of Assessment Tools
      • To be useful, assessment tools must be standardized and have clear reliability and validity
        • To standardize a technique is to set up common steps to be followed whenever it is administered
        • One must standardize administration, scoring, and interpretation
    • Characteristics of Assessment Tools
      • Reliability refers to the consistency of a test
        • A good test will yield the same results in the same situation
        • Two main types:
          • Test – retest reliability
            • To test for this type of reliability, a subject is tested on two different occasions and the scores are correlated – the higher the correlation, the greater the test’s reliability
          • Interrater reliability
            • Independent judges agree on how to score and interpret a particular test
    • Characteristics of Assessment Tools
      • Validity refers to the accuracy of a test’s results
        • A good test must accurately measure what it is supposed to be measuring
        • Three specific types:
          • Face validity – a test appears to measure what it is supposed to measure; does not necessarily indicate true validity
          • Predictive validity – a test accurately predicts future characteristics or behavior
          • Concurrent validity – a test’s results agree with independent measures assessing similar characteristics or behavior
    • Clinical Interviews
      • Face-to-face encounters
        • Often the first contact between a client and a clinician/assessor
      • Used to collect detailed information, especially personal history, about a client
      • Allow the interviewer to focus on whatever topics they consider most important
    • Clinical Interviews
      • Conducting the interview
        • Focus depends on theoretical orientation
        • Can be either unstructured or structured
          • In unstructured interviews, clinicians ask open-ended questions
          • In structured interviews, clinicians ask prepared questions, often from a published interview schedule
            • May include a mental status exam
    • Clinical Interviews
      • Limitations:
        • May lack validity or accuracy
        • Interviewers may be biased or may make mistakes in judgment
        • Interviews, particularly unstructured ones, may lack reliability
    • Clinical Tests
      • Devices for gathering information about a few aspects of a person’s psychological functioning, from which broader information can be inferred
      • More than 500 different tests are in use
        • They fall into six categories…
    • Clinical Tests
      • Projective tests
        • Require that subjects interpret vague and ambiguous stimuli or follow open-ended instruction
        • Mainly used by psychodynamic practitioners
        • Most popular:
          • Rorschach Test
          • Thematic Apperception Test
          • Sentence Completion Test
          • Drawings
    • Clinical Test: Rorschach Inkblot
    • Clinical Test: Thematic Apperception Test
    • Clinical Test: Sentence-Completion Test
      • “I wish ___________________________”
      • “My father ________________________”
    • Clinical Test: Drawings
      • Draw-a-Person (DAP) test:
        • “Draw a person”
        • “Draw another person of the opposite sex”
    • Clinical Tests
      • Projective tests
        • Strengths and weaknesses:
          • Helpful for providing “supplementary” information
          • Have rarely demonstrated much reliability or validity
          • May be biased against minority ethnic groups
    • Clinical Tests
      • Personality inventories
        • Designed to measure broad personality characteristics
        • Focus on behaviors, beliefs, and feelings
        • Usually based on self-reported responses
        • Most widely used: Minnesota Multiphasic Personality Inventory
          • For Adults: MMPI (original) or MMPI-2 (1989 revision)
          • For Adolescents: MMPI-A
    • Clinical Test: MMPI Minnesota Multiphasic Personality Inventory
      • Consists of more than 500 self-statements that can be answered “true,” “false,” or “cannot say”
        • Statements describe physical concerns; mood; morale; attitudes toward religion, sex, and social activities; and psychological symptoms
        • Assesses careless responding & lying
    • Clinical Test: MMPI Minnesota Multiphasic Personality Inventory
      • Comprised of ten clinical scales:
        • Hypochondriasis (HS)
        • Depression (D)
        • Conversion hysteria (Hy)
        • Psychopathic deviate (PD)
        • Masculinity-femininity (Mf)
      • Scores range from 0 – 120
        • Above 70 = deviant
        • Graphed to create a “profile”
        • Paranoia (P)
        • Psychasthenia (Pt)
        • Schizophrenia (Sc)
        • Hypomania (Ma)
        • Social introversion (Si)
    • Clinical Tests
      • Personality inventories
        • Strengths and weaknesses:
          • Easier, cheaper, and faster to administer than projective tests
          • Objectively scored and standardized
          • Appear to have greater validity than projective tests
            • Measured traits often cannot be directly examined – how can we really know the assessment is correct?
          • Tests fail to allow for cultural differences in responses
    • Clinical Tests
      • Response inventories
        • Usually based on self-reported responses
        • Focus on one specific area of functioning
          • Affective inventories (example: Beck Depression Inventory)
          • Social skills inventories
          • Cognitive inventories
    • Clinical Tests
      • Response inventories
        • Strengths and weaknesses:
          • Increasing in use and number
          • Not all have been subjected to careful standardization, reliability, and/or validity procedures (BDI and a few others are exceptions)
    • Clinical Tests
      • Psychophysiological tests
        • Measure physiological response as an indication of psychological problems
          • Includes heart rate, blood pressure, body temperature, galvanic skin response, and muscle contraction
        • Most popular is the polygraph (lie detector)
    • Clinical Tests
      • Psychophysiological tests
        • Strengths and weaknesses:
          • Require expensive equipment that must be tuned and maintained
          • Can be inaccurate and unreliable
    • Clinical Tests
      • Neurological and neuropsychological tests
        • Neurological tests directly assess brain function by assessing brain structure and activity
          • Examples: EEG, PET scans, CAT scans, MRI
        • Neuropsychological tests indirectly assess brain function by assessing cognitive, perceptual, and motor functioning
          • Most widely used is the Bender Visual-Motor Gestalt Test
    • Clinical Test: Bender Visual-Motor Gestalt Test
    • Clinical Tests
      • Neurological and neuropsychological tests
        • Strengths and weaknesses:
          • Can be very accurate
          • At best, though, these tests are general screening devices
            • Best when used in a battery of tests, each targeting a specific skill area
    • Clinical Tests
      • Intelligence tests
        • Designed to measure intellectual ability
        • Composed of a series of tests assessing both verbal and nonverbal skills
        • Generate an intelligence quotient (IQ)
    • Clinical Tests
      • Intelligence tests
        • Strengths and weaknesses:
          • Are among the most carefully produced of all clinical tests
            • Highly standardized on large groups of subjects
            • Have very high reliability and validity
          • Because intelligence is an inferred quality, it can only be measured indirectly
    • Clinical Tests
      • Intelligence tests
        • Strengths and weaknesses:
          • Performance can be influenced by nonintelligence factors (e.g., motivation, anxiety, test-taking experience)
          • Tests may contain cultural biases in language or tasks
    • Clinical Observations
      • Systematic observation of behavior
      • Several kinds:
        • Naturalistic
        • Analog
        • Self-monitoring
    • Clinical Observations
      • Naturalistic and analog observations
        • Naturalistic observations occur in everyday environments
          • Can occur in homes, schools, institutions (hospitals and prisons), and community settings
          • Tend to focus on parent – child, sibling – child, or teacher – child interactions
          • Observations are generally made by “participant observers” and reported to a clinician
        • If naturalistic observation is impractical, analog observations are used in artificial settings
    • Clinical Observations
      • Naturalistic and analog observations
        • Strengths and weaknesses:
          • Reliability is a concern
            • Different observers may focus on different aspects of behavior
          • Validity is a concern
            • Risk of “overload,” “observer drift,” and observer bias
            • Client reactivity may also limit validity
            • Observations may lack cross-situational validity
    • Clinical Observations
      • Self-monitoring
        • People observe themselves and carefully record certain behaviors, feelings, or cognitions as they occur over time
    • Clinical Observations
      • Self-monitoring
        • Strengths and weaknesses:
          • Useful in assessing infrequent behaviors
          • Useful for observing overly frequent behaviors
          • Provides a means of measuring private thoughts or perceptions
          • Validity is often a problem
            • Clients may not receive proper training and instruction
            • Clients may not record information accurately
            • When people monitor themselves, they often change their behavior
    • Diagnosis: Does the Client’s Syndrome Match a Known Disorder?
      • Using all available information, clinicians attempt to paint a “clinical picture”
        • Influenced by their theoretical orientation
      • Using assessment data and the clinical picture, clinicians attempt to make a diagnosis
        • A determination that a person’s problems reflect a particular disorder or syndrome
        • Based on an existing classification system
    • Classification Systems
      • Lists of categories, disorders, and symptom descriptions, with guidelines for assignment
        • Focus on clusters of symptoms (syndromes)
      • In current use in the US: DSM-IV-TR
        • Diagnostic and Statistical Manual of Mental Disorders (4th edition), Text Revision
    • DSM-IV-TR
      • Published in 1994, revised in 2000 (TR)
      • Lists approximately 400 disorders
        • Listed in the inside back flap of your text
      • Describes criteria for diagnoses, key clinical features, and related features which are often but not always present
    • The DSM-IV-TR
      • Most widely used classification system in the US
      • Multiaxial
        • Uses 5 axes (branches of information) to develop a full clinical picture
        • People usually receive a diagnosis on either Axis   I or Axis II, but they may receive diagnoses on both
    • Lifetime Prevalence of DSM-IV-TR Diagnoses
    • The DSM-IV-TR
      • Axis I
        • Most frequently diagnosed disorders, except personality disorders and mental retardation
    • Major Axis I Diagnostic Categories Sleep disorders Adjustment disorders Impulse-control disorders Sexual and gender identity disorders Eating disorders Other conditions that are the focus of clinical attention Dissociative disorders Factitious disorders Somatoform disorders Mental disorders due to a general medical condition Delirium, dementia, amnestic, and other cognitive disorders Schizophrenia and other psychotic disorders Substance-related disorders Disorders first diagnosed in infancy and childhood Mood disorders Anxiety disorders
    • The DSM-IV-TR
      • Axis II
        • Personality disorders and mental retardation
          • Long-standing problems
      • Axis III
        • Relevant general medical conditions
      • Axis IV
        • Psychosocial and environmental problems
    • The DSM-IV-TR
      • Axis V
        • Global assessment of psychological, social, and occupational functioning (GAF)
          • Current functioning and highest functioning in past year
          • 0 – 100 scale
    • Is DSM-IV-TR an Effective Classification System?
      • Classification systems are judged by their reliability and validity
      • Here reliability = different diagnosticians agreeing on a diagnosis using the same classification system
        • DSM-IV-TR has greater reliability than any previous editions
          • Used field trials to increase reliability
        • Reliability is still a concern
    • Is DSM-IV-TR an Effective Classification System?
      • The validity of a classification system is the accuracy of information that the diagnostic categories provide
        • Predictive validity is of the most use clinically
        • DSM-IV-TR has greater validity than any previous editions
          • Conducted extensive literature reviews and ran field studies
        • Validity is still a concern
    • Is DSM-IV-TR an Effective Classification System?
      • Beyond concerns about reliability and validity, a growing number of theorists believe that two fundamental problems weaken the DSM-IV-TR:
        • Basic assumption that disorders are qualitatively different from normal behavior
        • Reliance on discrete diagnostic categories
    • Can Diagnosis and Labeling Cause Harm?
      • Misdiagnosis always a concern
        • Major issue is reliance on clinical judgment
      • Also present is the issue of labeling and stigma
        • Diagnosis may be a self-fulfilling prophecy
      • Because of these problems, some clinicians would like to cease the practice of diagnosis
    • Treatment: How Might the Client Be Helped?
      • Treatment decisions
        • Begin with assessment information and diagnostic decisions to determine a treatment plan
          • Use a combination of idiographic and nomothetic information
        • Other factors:
          • Therapist’s theoretical orientation
          • Current research
          • General state of clinical knowledge – currently focusing on empirically supported, evidence-based treatment
    • The Effectiveness of Treatment
      • More than 400 forms of therapy in practice, but is therapy effective?
        • Difficult question to answer:
          • How do you define success?
          • How do you measure improvement?
          • How do you compare treatments – treatments differ in range and complexity; therapists differ in skill and knowledge; clients differ in severity and motivation…
    • The Effectiveness of Treatment
      • Controlled clinical research and therapy outcome studies typically assess one of the following questions:
        • Is therapy in general effective?
        • Are particular therapies generally effective?
        • Are particular therapies effective for particular problems?
    • The Effectiveness of Treatment
      • Is therapy generally effective?
        • Research suggests that therapy is generally more effective than no treatment or placebo
        • In one major study using meta-analysis, the average person who received treatment was better off than 75% of the untreated subjects
    •  
    • The Effectiveness of Treatment
      • Is therapy generally effective?
        • Some clinicians are concerned with a related question: Can therapy can be harmful?
          • Has this potential
          • Studies report ~5% get worse with treatment
    • The Effectiveness of Treatment
      • Are particular therapies generally effective?
        • Generally, therapy-outcome studies lump all therapies together to consider their general effectiveness
          • One critic has called this the “uniformity myth”
        • It is argued that scientists must look at the effectiveness of particular therapies
          • There is a movement (“rapprochement”) to look at commonalities among therapies
    • The Effectiveness of Treatment
      • Are particular therapies effective for particular problems?
        • Studies now being conducted to examine effectiveness of specific treatments for specific disorders:
          • “ What specific treatment, by whom , is the most effective for this individual with that specific problem, and under which set of circumstances?”
        • Recent studies focus on the effectiveness of combined approaches – drug therapy combined with certain forms of psychotherapy – to treat certain disorders